Transcript of Cyberseminar
VIReC Clinical Informatics Seminar
PE-Web: A Web-Based Training Program for Providers in Prolonged Exposure for PTSD
Presenter: Kenneth J. Ruggiero, Ph.D.
January 21, 2014
This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at or contact:
Moderator: Good morning and good afternoon, everyone. This session is part of the VA information resource center’s ongoing clinical informatics cyber seminar series. The series’ aims are to provide information about research and quality improvement applications and clinical informatics, and also information about approaches for evaluating clinical informatics applications. Thank you to CIDER for providing technical and promotional support for this series.
Questions will be monitored during the talk in the Q&A portion of Adobe Connect, and will be presented to the speaker at the end of this session. A brief evaluation questionnaire will pop up when we close the session. If possible, please stay until the very end and take a few moments to complete it. Let us know if there is a specific topic area or a suggested speaker that you would like for us to consider for the future.
At this time, I would like to introduce our speaker for today, Dr. Kenneth Ruggiero. Dr. Ruggiero is Associate Director and Research Health Scientist at the HSR&D Center of Innovation, Ralph H. Johnson VAMC. He is also Professor and Director of Research Coordination in the Department of Psychiatry and Behavioral Sciences at Medical University of South Carolina. Without further ado, may I present Dr. Ruggiero?
Dr. Ruggiero:Thank you, Erica. I appreciate that. I just wanted to—I’m glad that we have so many participants on the line. I am excited to share with you Prolonged Exposure Web, PE-Web, which is an online web training program. It takes about eight to ten hours to complete, and it’s designed primarily for VA providers who see veterans with PTSD, but also can be used by civilian providers who treat a wide variety of populations with PTSD or who might use prolonged exposure.
Most of the site is pretty veteran-centric, so a lot of the videos related to veteran scenarios and military backgrounds. A lot of the cues are military related, so you certainly get that feel for it on the site. At the same time, we’ve found that when we create sites like this, when we’re designing them, to increase training specific to a particular diagnosis like PTSD or depression, that they can be valuable when used with a variety of different populations. Even those of you who might not spend a lot of your time treating veterans specifically would find benefit from this, I think.
As Erica said, I’m at the Charleston VA COIN, the HSR&D Center of Innovation here at the Ralph H. Johnson VAMC. I’m also at the Medical University of South Carolina. Here at the Medical University of South Carolina, we’ve actually had a long history—an eight-year, eight- or nine-year history—of developing these types of sites.
Let’s see if I could—there we go—remember how to go to the next slide. What I’m going to cover in this presentation is I’m going to spend a very small amount of time talking about the behavioral health needs of veterans, different mental health diagnoses that are prevalent in the population. I’m sure many of you already know that, so I won’t spend a lot of time with that.
Then I’ll talk about providers’ readiness to deliver evidence-based treatment. In that context, I’ll talk about the VA dissemination initiative, where we’re rolling out prolonged exposure and also cognitiveprocessing therapy and other interventions such as behavioral activation that have been shown to be effective in treatment of post-traumatic stress disorder and depression.
In that context, we are hoping that web training sites like PE-Web can be very valuable in the process. I think there’s potential for it to have value in the pre-workshop phase and also in the post-workshop phase as a refresher course or as just an ongoing resource that providers can use.
I’ll talk about web-based training approaches in particular, and I’ll highlight one of the web-based resources that we developed here several years back, because we now have a lot of evaluation data over the years on that. I’ll show you some of the user reactions that we’ve had, some of the knowledge change data that we have on that, and give you a little bit more insight into what we see in our databases about how people are using the site, how many people are accessing, how many people are completing, what types of knowledge change levels are we seeing, and so on and so forth.
I’ll talk briefly about the process of developing PE-Web. I realize there are possibly some folks in the audience who are interested in developing sites like this, so learning a bit more about the steps that we took to put it together might be of value to you. Finally, I’ll give you a brief description of the PE website. I won’t spend a lot of time with that, because anybody can go to the site. It is now fully publically accessible. I’ll give you the website so that anybody can log on, if you’d like to, and use the training. I’ll provide some screen shots and give an overview of each of the main sections of PE-Web, as well.
I have to also acknowledge that there were many—as you can imagine, a project like this is a major undertaking and it requires a lot of collaboration from a lot of different areas of the country. First and foremost, Edna Foa was a key collaborator on this project. She had her hand—I don’t know how she does it, given how busy she is and how senior she is, but she had her hand in every piece of this.
She is featured on videos on just about if not all of the components of the website—I believe every module on the website, or every one with the exception of one or two—she is, there is a video with her describing the component and explaining some of the key challenges that providers often encounter in those components. Those, in and of themselves, are very valuable contributions, I believe, and unique. In addition to that, with all of the content development that we had, with all of the outlining, all of the web design decisions; she had a role in all of those. I thank her for that.
We also have several folks here. We have content development experts—Alyssa Rheingold is the content development expert here locally at the Medical University of South Carolina. Marty Strachan was also a major contributor to the content development at MUSC and at the Ralph H. Johnson VA. I won’t go through everybody.
Ron Acierno is featured in a lot of our videos. He’s the director of the PTSD clinical team at the Ralph H. Johnson VA Medical Center. Our technology team included Mary Mauldin and Jonathan Coultas, who helped a lot with videos, and Cheryl-Lyn Samuels, who is our primary programmer. She’s a person I go to when folks identify new issues that they’re encountering on the site as they’re using it currently.
I also had several external collaborators—Joe Ruzek who is the director of the dissemination branch at National Center for PTSD. He obviously has major roles in the PE rollout, as well as Afsoon Eftekhari, who has been instrumental in alpha and beta testing and making sure that—she has reviewed the site I don’t know how many times, but an enormous number of times. Also Ken Weingardt and Jessica Hamblen, who played a key role in helping to make some initial web design decisions and being involved at several steps throughout the process.
I’ll speak briefly about just a quick review, overview of veterans’ mental health needs. As we know, veterans are at risk for a wide range of behavioral health problems. The two in particular that are most relevant to this presentation are posttraumatic stress disorder and also depressed mood. Substance use problems also are co-morbid, quite frequently, with posttraumatic stress disorder. We also know that untreated PTSD and untreated depression, if they go for too long, may negatively affect overall health and wellness and will affect trajectories of recovery over time.
It’s importantthat we make sure that veterans have access to effective treatment for PTSD. That’s been a major priory in VA for quite a while. We really stepped up to the plate, I think, with the dissemination initiative, to make sure that providers across the nation have access to being able to deliver all the best treatments that are available for PTSD and depression. I don’t know exactly how many people have gone through the rollout process, but I believe we’re well into the thousands at this point.
We know that prolonged exposure is one of the best practice interventions that were identified by the Institute of Medicine, so it’s important that we place priority on interventions like that that we know are effective in treating veterans. That’s what we did here.
How does web-based training fit into all of this? First of all, I mentioned the National Dissemination Initiative. If you want to get a little bit more information on this, it’s about a three-year-old article now, so it’s a little bit outdated, but Brad Karlin, Joe Ruzek and others published a paper in Journal of Traumatic Stress where they talked a little bit more about some of the evaluation data they had on the National Dissemination Initiative.
Essentially, that entails providers going through about four-day workshop period for prolonged exposure. They then need to go through an ongoing consultation process with several folks, where they—I don’t know too much about this, but they essentially follow two cases all the way through from start to finish and receive consultation on an ongoing basis as they complete those sites.
As I talk to you today about Prolonged Exposure Web, PE-Web, be aware that we strongly feel that PE-Web is not intended in any way, shape or form to serve as a stand-along training protocol. It’s an eight- to ten-hour course; it’s meant to be used as an ongoing resource, as a preparation training resource for people who are about to enter a workshop, or as a refresher course, but certainly no way, shape or form as a stand-alone training protocol.
We set out, in this project, to identify sort of ways through technology that we can augment the training process. We believe that if providers have access to ongoing training materials online that that can improve their preparation to deliver interventions like prolonged exposure. There are lots of different ways that it can be used, as I mentioned, but in addition to that, before we end today I’ll tell you about some—an ongoing project that we have with Dr. Foa and her group to make smartphone resources available to supervisors and also to providers. That’s just early on in the process at this point. That is to say, essentially, that we’re looking for more ways beyond PE-Web technology can improve providers’ preparation and delivery of prolonged—interventions like prolonged exposure.
At this point, I think this opens it up for a quick poll. I just ask, “Have you completed a web-based training protocol in the past?”
[Pause 11:52—12:06]
Very interesting. It looks like almost exactly 50-50. I kind of expected that, but wasn’t too sure. Looks like several folks have done that and may be familiar with some of the types of approaches that I’m talking about, and others are pretty new to the process. That’s good. That’s a good mix.
I wanted to talk a little bit about prior successes. Not just to brag about the colleagues that I have here at the VA, but also at MUSC, but more importantly really to teach you what we’ve learned in the past. Because PE-Web is something that’s a new training protocol that’s available now, but because we just recently made it available, we do not have a lot of evaluation data on that specifically.
I thought that we—it wouldn’t have much benefit to show you some of the evaluation data that we’ve collected for PE-Web at this early stage when I really can feature that we developed back in 2005, for which we’ve had eight years of data collection, and I can show you a lot more in terms of the number of completers, the number of people who register for the course, and what we’ve learned with regard to usability testing and knowledge change over time.
We’re pretty experienced in this; we’ve done this over a period of several years. It started out with our development of trauma-focused cognitive behavioral therapy that—all the sites, you can see the web links there, and you’re welcome to use any of those sites. All of them are freely accessible, and all of them provide CE credits, CE certificates at the end that you can turn in to your licensing board.
You may want to talk to your licensing board in advance if you’re not sure about whether or not they accept these. In our experience, we haven’t had a lot of issues with that. Because MUSC has the authority to provide these, has permission from APA and others to provide these online training courses, we haven’t had a lot of, encountered a lot of problems with people getting their certificates accepted.
Folks are welcome to go to those sites and use those sites, but Trauma Focused CBT was led by Ben Saunders here, and Dan Smith. Cognitive Processing Therapy was led by Connie Best. I was involved in several of these. Helping Heroes, I led. That was the development of a web training resource for providers who serve first responders and firefighters.
We featured in that approach therapeutic exposure and behavioral activation. There are some critical differences between that and Prolonged Exposure Web, but you may also find Helping Heroes valuable. It doesn’t feature any veteran scenarios, but it’s certainly relevant to the population in a number of ways.
Okay. You can also see the name of the site—I can’t exactly remember how to use the pointer, so I better not do that. [Laughs] Actually, no, I think I might be able to do that. You can see here, dark colored, I just circled the website if you would like to go to the website PE-Web, that’s how you get there. It’s pe.musc.edu.
Okay. I’ll go through some TF-CBT Web data. It was funded by SAMHSA back in 2003, I believe. It was, like PE-Web, and eight- to ten-hour, web-based training course for providers. Just like PE-Web, it’s a free learning opportunity. Nobody has to pay anything to use it. You get a CE certificate at the end of the course.
It’s asynchronous learning, so there’s nobody on the other end. You sort of learn at your own pace. You could potentially complete it in one day, or you could complete it in two weeks. In one case, you could see probably later, that it might take a thousand days to complete it! There are some cases of that.
It was developed, took about two years to develop, and it was launched in October of 2005. I have a few screen shots, and I’ll talk a little bit about some features that the site has which are similar to the features that PE-Web has, even though we use a different platform for that. It is meant to train providers in trauma focused CBT for children. It is—it provides ten hours of CE credits. It’s, as I mentioned, a learn-at-your-own-pace course.
Our goal, essentially, is to make sure that all of our content, all of our explanations, all of our clinical challenge scenarios, are very concise, to the point, and not overly text-heavy. We always do our best to try to limit the amount of text that we have on a page. Sometimes that can get very difficult, because there are so many important components of several of the sites—of several of the interventions that we’ve been featuring on these sites. That can often be a challenge, to make some of these explanations and pieces of content concise, but we do try to do our best to limit the amount of text and provide as many video demonstrations as we can so that people have a clear understanding of how different pieces of the protocol can be implemented.
We do try to provide a lot of video demonstrations in each component, and I believe that you’ll feel that way on PE-Web. We have clinical scripts that you can use and you can print out before a session, if you think that that might be helpful in providing a rationale for providers—or, I’m sorry, for patients in addressing a certain challenge that you might be encountering in treatment. We provide some of those scripts. We also—in this case, for TF-CBT Web, one of our biggest features on the site was a cultural considerations component and a clinical challenge component. We address a lot of the clinical challenges as well in PE-Web.
The evaluation data that I’m going to present to you is over a five-year period between October 2005 and September 2010. It doesn’t cover the last three years, but I think you’ll find that it has a lot of data to really illustrate what we’ve learned from evaluation of the site. Back in September of 2010, by that point, over that five year period, we had already accumulated 73,000 registered learners.